NOV-04-2015 11:56 71BERNARDAMLINSMD P.01

EFTA00622056 Dataset 9 5 pages Download original PDF Download as text
NOV-04-2015 11:56 71BERNARDAMLINSMD P.01 BERNARD A. RAWLINS, MD HOSPITAL FOR SPECIAL SURGERY ADULT AND PEDIATRIC SPINE SURGERY FACSIMILE. TRANSMITTAL SHEET TO: LESLEY CiROFF FROM: BR] ANNA COMPANY: DATE: NOVEMBER 5, 20/5 FAX NUMBER: TOTAL NO. OF PAGES INCLUDING COVER: 5 PHONE NUMBER: SINDF.R'S REFERENCE NUMBER: YOUR REFERENC:E NUMBER: URGENT X FOR REVIEW ❑PLEASE COMMENT ❑ PLEASE REPLY 0 PLEASE RECYCLE MYtt.S./CO2.O4ENTS: Requested MRI results for Mr. Epstein. Thank you, Rrianna 523 EAST 72" STREET (2" FLOOR) NEW YORK, NY 10021 EFTA00622056 NOV-04-2015 11:56 71BERNARDRAWLINSND FAld oim cwweennai and tor the sole use of the into eat% • / I" HOSPITAL FOR SPECIAL SURGERY 535 East 70th Street New York, N.Y. 10021 DEPARTMENT OF RADIOLOGY AND IMAGING Check -in Date: 11/03/15 1514 Chk-in # Order Exam 4121712 0001 Patient Name Location EPSTEIN,JEFFERY DIS Ordering Physician RAWLINS,BERNARD A Adm/Reg Physician Consulting Physician RAWLINs,BERNARD A Medical Record # Date of Birth Age 840411 01/20/53 62y 0533 MRI LUMBAR SPINE Ord Diag: M48.06 -SPINAL STENOSIS, LUMBAR Page :1 MRI lumbar spine: Spin-echo sagittal, axial and coronal sequences were obtained and a STIR sagittal sequence. Patient history: Leg weakness and numb sensation in the legs. The lower thoracic spinal cord and conus medullaris are normal. T12-L1: There is no stenosis. L1-2: Disc degeneration is identified. There is moderate right and mild left facet arthrosis and no stenosis. L2-3: Disc degeneration is present and a minimal retrolisthesis. There is mild/moderate right and mild left facet arthrosis along with mild thickening of the ligamenta flava. Mild/moderate central canal stenosis is identified and the stenosis is partially on a developmental basis. There is mild left and mild/moderate right neural foraminal stenosis. A small/moderate sized disc protrusion projects into and slightly lateral to the right neural foramen and causes minimal impingement of the right L2 nerve root immediately lateral to the neural foramen. L3-4: Disc degeneration is present. Moderate/severe right and moderate left facet arthrosis is associated with thickening of the ligamenta £lava. Moderate central canal stenosis is identified and the stenosis is partially on a development basis. There is mild/moderate left neural foraminal stenosis and a small/moderate sized disc protrusion projects into and slightly lateral to the neural foramen and causes mild Page :1 , Report Continued on Next Page RAWLINS BE NARD A FINAL FINAL -262;:262;0533:4121712-0533- EFTA00622057 N00-04-2015 11:56 71BERNARDRAWLINSMD „__ _. LICN Sn Ldh y9 privileged aim cnntlitential and tor the role urn of tha intended tern. F. k1.5 Mic HOSPITAL FOR Ma SPECIAL SURGERY 535 East 70th Street New York, N.Y. 10021 DEPARTMENT OF RADIOLOGY AND a< IMAGING Check -in Date: 11/03/15 1514 Checkin-Exam Code Summary 4121712-0533 Patient Name EPSTEIN,JEFFERY Ordering Physician RAWLINS,BERNARD A Adm/Reg Physician Consulting Physician RAWLINB,SERNARD A Medical Record # Date of Birth 840411 01/20/53 Location DIS Age 62Y (Continued) Page 2 impingement of the left L3 nerve root at the exit zone and slightly lateral to the neural foramen. There is mild/moderate right neural foraminal stenosis and a small/moderate sized disc protrusion projects into and slightly lateral to the right neural foramen and causes minimal impingement of the right L3 nerve root at the exit zone of the neural foramen. L4-5: Disc degeneration is present and mild posterior bulge of the disc. There is a prominent fissure in the outer annulus adjacent to the left neural foramen. Severe facet arthrosis is associated with an approximate 2 mm anterolisthesis. There is thickening of the ligamenta flava and severe stenosis of the central canal and the subarticular recesses. The stenosis is partially on a developmental basis. There is a small collection of fluid located subjacent to the left ligamentum flavum, medial to the left facet joint, and possibly a very small collection of fluid in the right ligamentum flavum. The L5 nerve roots exit the thecal sac approximately 7 mm caudad to the disc space. Severe left neural foraminal stenosis causes impingement of the left L4 nerve root. There is moderate right neural foraminal stenosis and a small/moderate sized disc protrusion projects into the neural foramen and impinges the right L4 nerve root. LS-S1: Disc degeneration is present. Severe right and mild left facet arthrosis is detected and mild/moderate central canal stenosis, that is partially on a developmental basis. There is compression of the S1 nerve roots, more prominent on the right, between the facets and the disc, depicted in axial images 13-14 in series 6. Mild left and moderate right neural foraminal stenosis is detected. Page :2 , Report Continued on Next Page RAWLINS BERNARD A FINAL FINAL -262;;262;0533;4121712-0533- EFTA00622058 NOV-04-2015 F.U4 11:57 71BERNARDRAWL INSMD Lu aim Lb Innislege° ano contado.ntia1 and fin the sole uncr of thP intondch1 rot: WHOSPITAL FOR SPECIAL SURGERY 535 East 70th Street New York, N.Y. 10021 DEPARTMENT OF RADIOLOGY AND • IMAGING Check -in Date: 11/03/15 1514 Checkin-Exam Code Summary 4121712-0533 Patient Name EPSTEIN,JEFFERY Ordering Physician RAWLINS,BERNARD A Adm/Reg Physician Consulting Physician RAWLINS,BERNARD A Medical Record # Date of Birth 840411 01/20/53 Location DIS Age 62Y (Continued) Page 3 There is partial ankylosis of the anterosuperior compartment of the SI joints. Impression: 1. L1-2: Disc degeneration. Facet arthrosis. 2. L2-3: Disc degeneration. Mild/moderate central canal stenosis. Small/moderate sized disc protrusion projects into and slightly lateral to the right neural foramen and causes minimal impingement of the right L2 nerve root immediately lateral to the neural foramen. 3. L3-4: Disc degeneration. Facet arthrosis. Moderate central canal stenosis. Small/moderate sized disc protrusion projects into and slightly lateral to the left neural foramen and causes mild impingement of the left L3 nerve root at the exit zone and slightly lateral to the neural foramen. Small/moderate sized disc protrusion projects into and slightly lateral to the right neural foramen and causes minimal impingement of the right L3 nerve root at the exit zone of the neural foramen. 4. L4-5: Disc degeneration. Grade 1 degenerative anterolisthesis. Severe stenosis of the central canal and the subarticular recesses. Severe left neural foraminal stenosis causes impingement of the left L4 nerve root. Moderate right neural foraminal stenosis and a small/moderate sized disc protrusion projects into the neural foramen and impinges the right L4 nerve root. 5. L5-91: Disc degeneration. Facet arthrosis, more prominent on the Page :3 , Report Continued on Next Page RAWLINS,BERNARD A FINAL FINAL -262;;262;0533;4121712-0533- EFTA00622059 NOV-04-2015 11:57 P . 05 71BERWRDRAWL I NSMD I.SA • V. Ylleytm WA, wmaucnutll ana tor Lae Cole us• oi tar, intended rec. • / i• HOSPITAL FOR SPECIAL SURGERY 535 East 70th Street New York, N.V. 10021 DEPARTMENT OF RADIOLOGY AND IMAGING Check -in Date: 11/03/15 1514 Checkin-Exam Code Summary 4121712-0533 Patient Name EPSTEIN,JEFFERY Ordering Physician RAWLINS,BERNARD A Adm/Reg Physician Consulting Physician RAWLINS,BERNARD A Medical Record # Date of Birth Age 840411 01/20/53 62Y Location DIS (Continued) Page 4 right. Compression of the S1 nerve roots, more prominent on the right, between the facets and the disc. Mild/moderate central canal stenosis. 6. The results of the MRI exam were reported to Dr. Rawlins on 11/4/2015. Ordering Diagnosis ICD 10: M48.06: SPINAL STENOSIS, LUMBAR REGION Dictated By- RICHARD HERZOG M.D. Personally Viewed- RICHARD HERZOG M.D. Agreed with- RICHARD HERZOG M.D. Released Date Time- 11/05/15 0748 Page :4 , End of Report RAWLINS,BERNARD A FINAL FINAL -262;;262;0532;4121712-0533- TOTAL P.05 EFTA00622060

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[Image 1] The image appears to be a document scan, specifically a letter or a report. It contains text that is too small to read clearly, and there are no visible names, dates, places, or logos that can be discerned from this image. The document is addressed to a recipient, but the details of the recipient, the sender, or the content of the letter are not visible due to the resolution and size of the image. [Image 2] The image shows a document that appears to be a medical report or a clinical note. It includes sections such as "Patient Information," "Chief Complaint," "History of Present Illness," "Past Medical History," "Social History," "Family History," "Physical Examination," "Laboratory Data," and "Imaging Studies." There are visible fields for patient name, date of visit, and clinical notes. The document [Image 3] The image shows a document that appears to be a medical report or a clinical note. It includes sections such as "Patient Information," "Chief Complaint," "History of Present Illness," "Past Medical History," "Social History," and "Physical Examination." There are also sections for "Assessment and Plan" and "Orders." The document is filled with text, which includes patient information, symptoms, me [Image 4] The image shows a document that appears to be a medical record or a clinical note from a healthcare facility. The document includes sections for patient information, date and time of the encounter, and a section for the clinician's notes. There are visible fields for patient name, date of birth, and age, but the specific details are not fully visible. The clinician's notes mention a diagnosis and [Image 5] The image shows a document that appears to be a medical bill or invoice. It includes sections for the patient's name, date of service, and a list of services provided with corresponding charges. There is also a section for the total amount due. The document is from a medical facility, as indicated by the header and the nature of the services listed. The visible text includes the name "Richard A. L